Healthcare Provider Details

I. General information

NPI: 1801679899
Provider Name (Legal Business Name): SHIRLEY LOUIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 3RD ST NW STE 203
WINTER HAVEN FL
33881-4638
US

IV. Provider business mailing address

65 3RD ST NW STE 203
WINTER HAVEN FL
33881-4638
US

V. Phone/Fax

Practice location:
  • Phone: 863-449-3963
  • Fax:
Mailing address:
  • Phone: 863-449-3963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number23-1405
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: